Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Midwifery Pharmacology — The Limited FormularySummary

The midwife's drug list is intentionally narrow and focused on essential, life-saving interventions for normal pregnancy, birth, and the postpartum period. It includes oxytocics (for normal third stage and PPH emergency), newborn prophylaxis, micronutrients, vaccines, family planning agents, and the magnesium sulfate loading dose for eclampsia. Every other drug category — antibiotics for infection, labor induction drugs, general anesthesia, antihypertensives, insulin, anticoagulants — is explicitly outside the midwife's scope. This legal and clinical boundary is enforced by the PRC and is high-yield on the MLE.

Oxytocin (synthetic oxytocin, a posterior pituitary hormone analog) 10 IU given intramuscularly is the gold-standard uterotonic for Active Management of the Third Stage of Labor (AMTSL). It must be given **within one minute of delivery of the baby** (after ruling out a second twin), not before. AMTSL has three components: (1) oxytocin 10 IU IM within 1 minute of birth, (2) controlled cord traction with counter-traction during a contraction, (3) uterine massage every 15 minutes for 2 hours postpartum. Oxytocin is the preferred first-line drug because it has rapid onset, effective contractility, and crucially does NOT raise blood pressure — making it safe when maternal BP is unknown or elevated. For PPH treatment, oxytocin can be repeated and, where IV access and protocol allow, infused (e.g., 20–40 IU in 1 L isotonic fluid) while arranging urgent referral.

Ergometrine (or methylergometrine) 0.2 mg IM is a potent uterotonic that causes sustained uterine contraction and is used for PPH when oxytocin is unavailable or insufficient. However, it carries a major safety liability: **it causes systemic vasoconstriction and raises blood pressure**. It is absolutely contraindicated in hypertension, pre-eclampsia, eclampsia, and cardiac disease. Because a midwife in a resource-limited setting (BHS, lying-in) cannot always reliably rule out these conditions at first contact, **oxytocin remains the first-choice uterotonic**, and ergometrine is reserved for specific PPH protocols where blood pressure is confirmed as safe.

Misoprostol (a prostaglandin analog) is a heat-stable alternative for AMTSL (600 mcg orally immediately after birth) and for PPH treatment (800 mcg) in settings where oxytocin cold-chain storage is unreliable or unavailable. The Philippines' DOH/BEmONC protocols recognize misoprostol as a valid option for community-level use because it does not require refrigeration and remains potent in tropical climates. It causes both uterine contraction and increased blood flow, making it effective for PPH. Side effects include fever, diarrhea, and nausea, but these are generally mild and transient.

Every newborn receives Vitamin K1 (phytomenadione) IM within the first hour(s) after birth to prevent **Vitamin K Deficiency Bleeding (VKDB)**, formerly called hemorrhagic disease of the newborn. VKDB is a rare but serious life-threatening bleeding disorder that can occur in the first week to few months of life if not prevented. Vitamin K is essential for synthesis of clotting factors II, VII, IX, and X. Newborns have low gut flora and minimal transplacental vitamin K; breast milk is low in vitamin K, so supplementation is critical. **Dose: 1 mg IM for a term infant (≥1.5 kg), 0.5 mg IM for a preterm/low-birth-weight infant (<1.5 kg).** Route: **IM into the anterolateral thigh (vastus lateralis muscle)**. Single dose only. It is safe, effective, universally recommended by WHO/DOH, and part of the Unang Yakap protocol.

Every newborn receives eye prophylaxis to prevent **ophthalmia neonatorum**, a severe and potentially vision-threatening conjunctivitis caused by gonococcal (Neisseria gonorrhoeae) or chlamydial (Chlamydia trachomatis) infection acquired during vaginal delivery from an infected mother. The DOH-preferred agent is **erythromycin 0.5% ophthalmic ointment**, applied as a thin ribbon to the lower conjunctival sac of each eye (alternatively tetracycline 1% ointment). Silver nitrate drops are the historical gold-standard agent but are rarely used now. **Timing**: apply **within the first hour after birth**, ideally after eye-to-eye and skin-to-skin contact and drying, to avoid interference with bonding. **Critical**: do **not irrigate the eyes afterward**; the ointment acts as a protective film. If ointment enters the eye and infant fusses, gentle wiping is acceptable, but flushing is not needed and may reduce efficacy.

Every pregnant woman in the Philippines receives iron and folic acid supplementation as a routine antenatal preventive measure. The DOH standard is **ferrous sulfate 60 mg elemental iron + folic acid 400 micrograms (0.4 mg) once daily** throughout pregnancy and continued for **3 months postpartum**. This prevents and treats pregnancy anemia (which is common due to expanded plasma volume and increased fetal demands). In women with frank anemia (hemoglobin <7 g/dL or clinical signs), iron dose may be increased to **twice daily** under protocol. Folic acid supplementation also reduces the risk of neural tube defects in the fetus. The midwife counsels on adherence (take with vitamin C-rich foods to enhance absorption, avoid taking with milk/antacids which reduce absorption, expect dark stools) and watches for side effects (constipation, nausea—which can improve with food or dose timing adjustment).

High-dose Vitamin A (>10,000 IU daily) is **absolutely contraindicated in pregnancy** because it is teratogenic and causes birth defects (cleft palate, cardiac, urogenital, and CNS malformations). Postpartum, where DOH/RHU protocol allows, **Vitamin A 200,000 IU** may be given to the mother within the first weeks after delivery to support postpartum recovery and immune function, and later in the puerperium if breastfeeding is not established or supplementary feeding is used. Vitamin A supplementation in infants and children (not postpartum mothers) is covered under child-nutrition policy and is part of the National Immunization Program (NIP) schedule at 9 months and 2 years. The midwife must counsel women to **avoid high-dose vitamin supplements during pregnancy** and to clarify this distinction to avoid teratogenic exposure.

The midwife administers **tetanus-containing vaccine (currently Td — tetanus-diphtheria)** to pregnant women to prevent both maternal tetanus and **neonatal tetanus (MNT)**, a potentially fatal infection in the newborn caused by *Clostridium tetani* contaminating the umbilical stump (especially in traditional settings with non-sterile cord cutting/tying). The protective schedule uses the classic **TT1–TT5 model**: **TT1** (as early as possible in pregnancy/first contact) provides no immediate protection; **TT2** (at least 4 weeks after TT1) provides ~3 years of protection and protects that pregnancy; **TT3** (at least 6 months after TT2) extends to ~5 years; **TT4** (at least 1 year after TT3) extends to ~10 years; **TT5** (at least 1 year after TT4) confers lifetime/lifelong protection for all future pregnancies. **Dose: 0.5 mL IM** (deltoid). A woman who has received **5 doses (fully immunized)** and her newborn are protected against tetanus. The vaccine is heat-stable but ideally stored at 2–8 °C and protected from light (cold-chain management is the midwife's responsibility).

For **severe pre-eclampsia and eclampsia**, the midwife may administer the **magnesium sulfate loading dose before and during referral** as a life-saving first-aid measure to prevent seizures and maternal death. **Standard loading regimen**: **4 g of MgSO4 (20% solution = 20 mL of 20% solution) slow IV over 5–20 minutes**, PLUS **5 g of MgSO4 (50% solution = 10 mL of 50% solution) deep IM into each buttock (10 g total IM)**, each IM dose mixed with **1 mL of 2% lignocaine** to reduce pain on injection. Onset of action is rapid (within minutes to hours). **Maintenance dosing (5 g IM every 4 hours in alternate buttocks) is the responsibility of a physician/facility**; the midwife's authority is limited to the **loading dose only**. Before and between doses, the midwife must monitor three **safety signs**: (1) **respiratory rate ≥12–16 breaths/min** (toxicity causes respiratory depression), (2) **urine output ≥30 mL/hr (or ≥100 mL/4 hr)** (to detect renal failure), and (3) **present patellar (knee-jerk) reflexes** (loss of reflexes is an early sign of toxicity). If any safety sign is absent (e.g., RR <12, no urine output, absent reflex) or if magnesium toxicity is suspected (nausea, confusion, muscle weakness, cardiac arrhythmia), **stop MgSO4 immediately** and administer the **antidote: calcium gluconate 1 g (10 mL of 10% solution) slow IV** to rapidly reverse toxicity. This is the most heavily tested anticonvulsant on the MLE.

Within primary care and community settings, the midwife provides **contraceptive services** including counseling and dispensing of: **(1) Combined oral contraceptives (COCs)** — e.g., ethinylestradiol + levonorgestrel — taken once daily; **(2) Progestin-only pills (POPs)** — e.g., norethisterone — taken once daily, preferred in lactating women because they do not reduce milk supply (COCs may reduce lactation); **(3) Injectable contraceptives — DMPA (depot medroxyprogesterone acetate) 150 mg IM every 3 months**, highly effective, reversible, and also preferred in breastfeeding women; **(4) Male and female condoms** for STI/HIV prevention and contraception. The midwife **does not insert IUDs or subdermal implants** — these require specific training and physician/specialist referral. She must screen for contraindications: **COCs are avoided in smokers aged >35 years, women with uncontrolled hypertension, history of thromboembolism, migraine with aura, and are not the first choice during full breastfeeding**. She provides ongoing counseling, manages minor side effects (e.g., breakthrough bleeding, nausea), and refers women with serious complications (e.g., chest pain, severe leg swelling in COC users).

The midwife must know exactly what is **forbidden** by law and scope: (1) **Antibiotics for treatment of infection** — e.g., amoxicillin, metronidazole, cephalosporins — are physician/facility drugs. The midwife may give a **pre-referral emergency dose** of antibiotic under specific protocol (e.g., IV ceftriaxone before transfer for sepsis), but ongoing antibiotic therapy is outside scope. (2) **Oxytocin for labor induction or augmentation** — oxytocin is **NOT used to speed up labor**; this is a physician act with major risks (uterine rupture, fetal death). Oxytocin use is confined to the **third stage (AMTSL) and PPH emergency**. (3) **General, regional, and spinal anesthesia** — all anesthesia is a physician/anesthetist responsibility. (4) **Controlled/narcotic analgesics** — e.g., morphine, pethidine, codeine — require physician prescription and specialized monitoring. (5) **Antihypertensive drugs** — e.g., nifedipine, methyldopa, labetalol — are physician responsibility; the midwife detects hypertension and refers. (6) **Insulin and other diabetes agents** — management of gestational/pre-existing diabetes is a physician/endocrinologist responsibility. (7) **Anticoagulants** — e.g., warfarin, heparin, enoxaparin — for thromboembolism prevention/treatment is physician scope. (8) **Corticosteroids** — e.g., dexamethasone, betamethasone — for fetal lung maturity in preterm labor is a physician responsibility (the midwife detects preterm labor and refers urgently). (9) **Ergometrine in a hypertensive woman** — drug-specific contraindication.

Whatever the drug, the midwife applies the **'rights' of medication**: (1) **right patient** — confirm identity via maternal/newborn record; (2) **right drug** — verify drug name, expiry, and integrity (color, clarity); (3) **right dose** — measure precisely (use calibrated syringes, not 'pinches' or 'handfuls'); (4) **right route** — IM (deltoid for vaccines, vastus lateralis for newborn Vitamin K), IV (MgSO4 loading dose), oral (iron, folic acid, POPs/COCs, misoprostol), or ophthalmic (eye prophylaxis); (5) **right time** — timing critical (oxytocin within 1 minute of birth, Vitamin K within first hour, eye prophylaxis within 1 hour); (6) **right documentation** — record every dose on the mother's antenatal/natal card, newborn's birth record, and in FHSIS (Family Health Survey Information System) registers/LDR (Labor and Delivery Register); (7) **check for allergies** — ask before injection (though true drug allergy is rare in the limited formulary). **Cold-chain management** is essential for vaccines and oxytocin: store at **2–8 °C** (not frozen, not room temperature), use a functioning refrigerator with a thermometer, protect from light, and check cold-chain indicators (freezer packs) before use. **Sharps safety**: use **sterile single-use needles and syringes**, never reuse, and dispose in a puncture-proof sharps container. **Anaphylaxis preparedness**: have adrenaline (epinephrine) 0.5 mg IM available when giving any injection (vaccines, oxytocin, MgSO4); watch for signs (urticaria, angioedema, stridor, hypotension, syncope) within 15–30 minutes and be ready to treat.

Oxytocin 10 IU IM within 1 minute of birth is the first and most critical step of AMTSL. AMTSL (which also includes controlled cord traction and uterine massage) significantly reduces PPH risk and is the evidence-based, life-saving standard for all vaginal births globally and in the Philippines. PPH is the #1 direct maternal killer, so mastering this relationship is the single most important clinical skill in the midwife's practice.

Vitamin K1 IM prevents VKDB (potentially fatal bleeding), and eye prophylaxis (erythromycin ointment) prevents ophthalmia neonatorum (potentially blinding infection). Together, these two injections/applications, given to every newborn in the first hour(s) after birth, constitute the essential newborn prophylaxis component of Unang Yakap and EINC protocols. Neither is optional; both are universal, simple, and life/vision-saving.

Daily iron (60 mg) + folic acid (0.4 mg) supplementation in pregnancy and 3 months postpartum prevents both maternal anemia (which increases infection and hemorrhage risk, impairs recovery) and fetal neural tube defects (spina bifida, anencephaly). This is a cornerstone of the midwife's antenatal preventive care and directly impacts maternal and newborn outcomes.

Maternal tetanus immunization protects the mother from tetanus infection and, critically, provides passive transplacental antibodies that protect the newborn from neonatal tetanus (MNT), a potentially fatal infection from contaminated cord-cutting/tying practices. Full immunization (5 doses) confers lifetime protection for all future pregnancies. This is a public-health triumph in the Philippines and is central to MNCHN programs.

The midwife detects signs of severe pre-eclampsia/eclampsia (hypertension, proteinuria, severe headache, visual changes, epigastric pain, altered consciousness, seizures). Magnesium sulfate loading dose is a life-saving first-aid intervention that rapidly enters the CNS and prevents seizures while the woman is being stabilized and transported to a facility with obstetric intensive care. MgSO4 is the only medication for which the midwife gives a loading dose of an ongoing drug (which is usually physician/facility responsibility) because it is a true emergency and delays are deadly.

The midwife's role in family planning is to counsel women on available methods, screen for contraindications, and dispense safe, effective agents (COCs, POPs, DMPA, condoms). Correct method choice (e.g., POP/DMPA in lactating women to avoid reduced milk supply) and good adherence support healthy pregnancy spacing, reduce maternal mortality (especially for women with <2 years interpregnancy interval), and enhance child survival. Family planning is an integral part of community MNCHN care.

The midwife's deliberately limited formulary is not a weakness but a strength: it focuses her expertise on essential, life-saving interventions for normal pregnancy and birth. By understanding the boundary (what is inside vs. outside her scope), the midwife practices safely, avoids serious drug errors, stays within the law (RA 7392), and ensures that women with complications are referred to appropriate physician/specialist care. Scope creep (giving drugs outside the formulary) puts patients at risk and violates professional standards.

Vaccines (Td) and oxytocin require storage at 2–8 °C (not frozen, not room temp). If cold-chain is broken (e.g., vaccine left in sun, oxytocin exposed to heat), potency is lost and the drug becomes ineffective. A woman vaccinated with a heat-damaged vaccine has no protection against tetanus; a woman given heat-damaged oxytocin may still develop PPH. The midwife's responsibility for cold-chain management directly impacts the safety and effectiveness of her interventions.